Exchange enrollees sicker than average

By BenefitsPro

Those who enrolled in health coverage through the exchanges aren’t as healthy as some would like, according to new data.

Analysis from Express Scripts shows that, based on their medication usage, PPACA enrollees are sicker than patients off the exchanges, often requiring specialty drug prescriptions.

The pharmacy benefit manager said that six of the top 10 costliest medications used by exchange enrollees have been specialty drugs — such as those used to treat HIV/AIDS, autoimmune disorders and cancer. In commercial health plans, four of the top 10 costliest medications were specialty.

“Our early analysis reveals that, in January and February, use of specialty medications was greater among exchange enrollees vs. patients enrolled in a commercial health plan,” Express Scripts said in its report. “Approximately 1.1 percent of total prescriptions in exchange plans were for specialty medications, compared to 0.75 percent in commercial health plans, a 47 percent difference.”

Analysis also found the proportion of medications specifically to treat HIV was nearly four times higher in the exchanges than in commercial health plans.

Also higher in exchange plans were the proportion of pain medications (35 percent higher in exchanges than in commercial plans), anti-seizure medications (27 percent higher) and antidepressants (14 percent higher). The proportion of contraceptives, however, was 31 percent lower in exchange plans.

Increased volume for higher cost specialty drugs can have a significant impact on the cost burden for both plan sponsors and patients, analysts said. Carriers’ per-member pharmacy costs so far this year are nearly 35 percent higher for their commercial plans versus their exchange plans, the report found.

Health experts say having healthy enrollees in Obamacare plans is important to offset the costs of sicker enrollees and hold down premiums in the coming years.

The Obama administration last week announced that 7.1 million people have enrolled in coverage under PPACA. They haven’t released the breakdown of exchange enrollees, identifying ages or demographics.

The analysis is based on a national sample of more than 650,000 pharmacy claims from January 1 through February 28 for patients enrolled in a public exchange plan with pharmacy benefit coverage administered by Express Scripts.

The analysis doesn’t include the late enrollment surge in PPACA plans in March. Julie Huppert, Express Scripts vice president of health care reform, warned the report is “a very early analysis.”

Experts have noted that sicker patients were expected to sign up for coverage first, while younger and healthy patients waited until the end of enrollment to sign up.